Chronic Candidal Paronychia

April 15, 2005

A 70-year-old woman complained of an infection in the right index fingernail and surrounding skin of 18 months' duration. The modest swelling and tenderness of the proximal paronychial tissue, faint nail dystrophy, and separation of the cuticle from the nail plate had persisted despite several courses of oral and topical antibiotics. The patient had occasionally seen pus seeping from underneath the cuticle. Results of a bacterial culture, performed by another physician, were negative.

A 70-year-old woman complained of an infection in the right index fingernail and surrounding skin of 18 months' duration. The modest swelling and tenderness of the proximal paronychial tissue, faint nail dystrophy, and separation of the cuticle from the nail plate had persisted despite several courses of oral and topical antibiotics. The patient had occasionally seen pus seeping from underneath the cuticle. Results of a bacterial culture, performed by another physician, were negative.

The chronicity, failure of antibiotic therapy, and physical findings pointed to chronic candidal paronychia. Joe Monroe, PA-C, of Tulsa, Okla, ordered a fungal culture that revealed Candida albicans. The diagnosis can usually be made clinically, however.

Paronychia is common. Candida organisms gain access to the subcuticular space, where they cause chronic erythema and slight swelling and tenderness of the proximal paronychial tissue.

Predisposing factors include female sex, immune suppression (from chemotherapy or prednisone therapy), and excessive exposure of the hands to water. The constant contact with water promotes separation of the cuticle from the nail plate and creates a point of entry for Candida organisms. Bacteria, dirt, and other foreign material (eg, food and lint) may also gain access to the subcuticular space and contribute to the chronic inflammation. For this reason, treatment with a corticosteroid cream is often required in addition to antifungal therapy.

In this patient, treatment with oral fluconazole, 100 mg/d for 3 weeks, and ciclopirox cream, applied twice daily, was effective.